To an overflow conference audience spilling into an outer hallway in July, the American Psychiatric Association presented its new guide for managing return-to-work for employees with mental-health problems.
The APA chose the annual conference of the Disability Management Employer Coalition, held in Boston, to unveil its guide. The tools, designed to help clinicians treating mental-health issues, are a work in progress and have yet to be piloted.
The authors of the guide face the formidable task of placing the guide into use. That will involve correcting flaws in how the healthcare community as a whole often treats mental-health problems as incompatible with work.
The APA's project director, Ed Muldoon, was ecstatic with the reception of DMEC conference attendees. At the conclusion of the session, he said, "We tried to get out the room as quickly as we finished. But on the way out, people were giving me their business cards, people with employers who had a problem with behavioral health disability. Clearly, we hit a very responsive nerve."
The guide declares that "restoration of work is a fundamental goal of treatment" for mental-health problems.
It has arrived not a moment too soon, given widespread unrest among employers and insurers about the toll of mental-health problems within the workforce.
As the APA guide notes, "Psychiatric disorders are recognized as the primary cause of occupational disability in at least 10 percent of private disability insurance claims and about 30 percent of Social Security disability claims.
"We estimate that in the private disability arena, an additional 20 percent to 40 percent of all claims involve co-morbid or secondary psychiatric problems that contribute directly to disability or impede rehabilitation and return-to-work."
The resource is a packet of clinical tools to expedite early and safe return to work for employees with depression, anxiety, phobias and other conditions. A landmark in itself, it also provides further evidence that healthcare providers are determined to catch up with employers and insurers in containing disability within the workforce.
While not expressly intended as such, the guide is a companion to the American College of Occupational and Environmental Medicine's guide to return-to-work and stay-at-work, published in 2006.
Jennifer Christian, an occupational medicine physician and lead author of the ACOEM guide, says, "What jumps out when reading the APA guide is the shared vision of work as part of therapy. Preserving normal daily routine helps people recover" from mental as well as physical disability.
Many employers and insurers have sharply criticized the healthcare community for huge inconsistencies in treating mental-health problems of workers and failing to grasp the importance of early return-to-work. This has resulted, in the eyes of many, in prolonged disability, lower productivity and higher insurance costs.
THAT'S ALL CHANGING
A pilot for the new APA guide was targeted to start in October and will involve psychiatrists and psychologists, according to Muldoon.
The authors of the guide expect to learn how to get mental-health specialists to use the guide. It will then have to crack a tougher nut--inducing primary-care doctors to collaborate with mental-health specialists in the use of the tools. Today, a large majority of employees use primary-care doctors for mental-health treatment, and for advice on staying out of and returning to work.
The authors do not expect that pattern to change much. They are counting on a moderate shift toward using mental-health specialists for treatment, with primary-care physicians also referring to these specialists on a consulting basis.
The APA authors want to induce health plans and employers to remove barriers to direct contact between troubled employees and mental-health specialists. One step, Muldoon says, is to equalize the co-pay for mental-health specialists with that for primary-care doctors. He says that, quite often, seeing a mental-health specialist requires a higher co-pay.
The group directly charged by the APA with bringing the guide to life is its Partnership for Workplace Mental Health. The Partnership is a standing coalition of clinicians, employers and insurers. The American Psychiatric Foundation arranged for funding.
The guide explains the importance of work as part of managing mental-health problems. It goes so far as to label inability to work as "a psychiatric crisis."
The authors attempt to correct key flaws in how primary-care clinicians and specialists handle their patients' work capacity. Not only do they often fail to value the therapeutic nature of work. They also tend to move too quickly from observing symptoms of mental problems to deciding that patients have work impairment and placing them on disability.
"Our work was not directed toward developing a treatment guideline," Muldoon says. "We decided the most practical contribution we could make would be to develop a method to objectively and reliably assess a patient's work function status and to use that assessment as the basis for treatment and return-to-work plans."
The guide leads the clinician to focus on the precise ways in which patients' problems create "impairments to daily functioning and with their job." The clinician is supposed to document how the problems affect cognition, such as comprehending instruction and concentration.
She is also to assess patients' moods, which affects their energy level and propensity for becoming irritable.
A third dimension is patients' ability to communicate appropriately and to contain behavior under adverse conditions. Then comes the fourth dimension, insight, or acting responsibility, such as in response to supervisor feedback.
A final dimension is judgment. The clinician needs to assess how her patient will act independently and observe appropriate boundaries in relationships.
The APA began fairly recently to pay serious attention to return-to-work issues. An important step was engaging Muldoon, a former Prudential Insurance Co. executive, to stir things up in 2004.
Muldoon recalls one of his first encounters with mental-health-related disability, when he assumed in 1991 the leadership of a Prudential unit to market disability insurance. (He retired in 2001.)
When he took over this unit, he says, "There was a customer that was posing a big problem. They were losing lots of money in disability losses, and no one had any real ideas about what to do. We did some analysis of the data, and it was clear that psychiatric problems were at the center of the client's problem. The treatment was pathetic. The diagnosis was uncertain in many cases. The treatment did not conform to any standard of medical care."
He learned that, among disability claimants with the same type of disability, some did not return to work but others did, even with the same level of disease.
A study by Harvard Medical School professor Ronald Kessler on employee disability convinced him further of the scope of a crisis in medical treatment.
"The Kessler study--what was shocking to me--the care standards, the average care delivered to patients in America, is really, really low, even compared to minimally adequate care. This is the first problem out there," he says.
"The second problem is that doctors are not really trained on function and work. You have a problem with doctors who do not seem to believe collectively that work is in the best interest of their patients.
"Stopping work presents a psychiatric crisis, not as severe as suicidal or homicidal ideation, but important," he continues. "And that was not recognized in the psychiatric community. If a suicidal or homicidal ideation appears, a clinician today knows what to do. But if a person says she or he needs to take time from work, the clinician asks, "Where do I sign the form?"
With Muldoon as project director, the APA mobilized its long-standing, but largely inactive, Partnership on Workplace Mental Health. The project surveyed 220 employers. The survey highlighted the degree of employer unrest, as well as their lack of preparation for early return-to-work. Most job descriptions, for instance, had no information about cognitive demands. The survey findings are included in the guide.
Muldoon says that the APA is working on a statement about the value of work. When will it be out? Who knows, he says. After all, Muldoon says, "They're doctors."
PETER ROUSMANIERE is a Vermont-based writer and columnist for Risk & Insurance®.
November 1, 2007
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